Thursday, February 10, 2011

Implementing skin-to-skin in a hospital

Alethea, a labor & delivery nurse in a small community hospital, wrote this guest post about how to implement skin-to-skin in a hospital. Sometimes a big change in policy starts with just one nurse's efforts! 

If you would like to get in touch with Alethea, please leave your email address in the comments or send me an email, which I will forward on to her. She is more than happy to answer your questions.

As expectant mothers near the end of pregnancy, they begin to prepare themselves mentally and physically for the upcoming birth of their baby. While imagining what labor and birth might be like for them, they often daydream about holding their baby in their arms for the first time, immediately after birth. It is instinctive for new mothers to want to hold their babies close, nourish them, and keep them safe and warm.

In recent years, studies have shown what mothers have known in their hearts since the beginning of time: that skin-to-skin contact immediately following birth is best for mothers and their healthy babies. Healthy newborns placed skin-to-skin on their mother have a surprisingly easy time adjusting to life outside the womb. Skin-to-skin contact helps keep babies warm. Babies also cry less, have more stable blood sugar levels, sleep more, experience less pain from painful procedures, and are interested in breastfeeding sooner than newborns who are separated from their mothers.

I am a labor and delivery nurse in a small community hospital. We attend the deliveries of 350-450 births per year. I began recognizing that it was not a part of our culture to support immediate skin-to-skin contact with new moms and babies. Often, doing as they were trained to do, nurses would whisk the baby over the warmer, clean her up, weigh her, measure her, administer baby meds, etc while the placenta was being delivered and the physician was repairing the mom’s perineum if needed. Often, I then witnessed the baby being wrapped up in multiple layers of blankets, with only his face visible to finally meet his mother mother for the first time 15-20 minutes after birth. My colleagues and I were simply task-oriented; we did not recognize what we were denying these moms and babies. We were all trained under a medical model of obstetrical care, and we were simply trying to get our jobs done as efficiently as possible. Ah, but old dogs can be taught new tricks (or ancient tricks that they just didn’t know yet)!

When I was first training as a labor and delivery nurse, I worked in a large urban city hospital that had both midwifery-model care delivered by certified nurse midwives, as well as medical-model care delivered by physicians. (Granted, some midwives seemed to function under the medical model and some physicians seemed more midwifery-model oriented, but that is another story.) In my training and subsequent employment, I witnessed the beauty and the benefits of providing immediate skin-to-skin contact between moms and babies, as it was strongly supported by the midwives with whom I worked. I feel so blessed to have had the midwifery model of care as a part of my training. Many moms and babies have benefited from what I learned from those midwives (and some physicians).

So, how did we go about changing the culture of our little community hospital? It all seems to be a bit of a blur, and I might be getting some of the details out of order. My apologies to my colleagues if that is the case! Taking into consideration that the predominate culture of our department has always been doing what is best for moms and babies, I think this particular change started with leading by example. When I attended a birth as the baby nurse (we always have two nurses attend every delivery, one for mom and one for baby), I began to put babies skin to skin with their moms. When I was the labor nurse, I urged the baby nurse to get the baby skin to skin as soon as possible, asking them to leave all the non-urgent admission tasks for me to complete later. If the baby was brought to mom all wrapped up, I would simply unwrap the baby and get him skin to skin with his mom. We began to have discussions at the nurse’s station about which of our nursing tasks can wait (most of them), and we talked about how easy it really is to do those tasks that could not wait right on the mom’s chest. For those nurses who felt they did not have time to come back later to do admission procedures on my babies, I volunteered to do everything myself. And slowly the culture started to shift.

In 2007, AWHONN published an article, Skin-to-skin Contact: Giving Birth Back to Mothers and Babies (PDF). I printed up copies of the article and left them around the department, requesting that all the nurses read it. I sent copies to the recovery room staff and anesthesiologist. Over time, I began to notice more nurses starting to incorporate skin-to-skin into their routine practices. We were gaining momentum.

Over the past couple of years, the nursing staff and physicians I work with have successfully integrated immediate skin-to-skin contact as a standard of care for healthy babies born by vaginal birth. Because we strongly believe in the importance of providing safe, quality, family centered maternity care, we are always looking for ways to improve the services we provide the new families in our community. So why stop what we now know is the right thing to do with just vaginal births?

We all know that when cesarean birth becomes necessary, it often brings an unexpected and unwelcome separation of the mother from her newborn baby. Even when cesarean births are planned, I can’t imagine the longing so many mothers must have felt during the time they are separated from their babies. It is not uncommon for it to take between 40 minutes to over an hour be reunited with their baby. (Side note: because we are a very small hospital, we do not staff our own operating room or recovery room.) As we witnessed the gentle transition to life outside the womb with infants placed skin to skin with their mothers after vaginal birth, I began to wonder why we could not also support this amazing time for healthy moms and their babies born by cesarean.

Our department was looking for a quality improvement goal for the upcoming year. At our staff meeting in November 2010, I suggested we begin to offer and support skin-to-skin contact in the operating room. We had already tried, with inconsistent success, to bring babies back to PACU (a recovery room that is staffed with different staff than the LD unit) to breastfeed. (Again, another story as to why that hasn’t been very successful.) So why not just prevent the separation in the first place and keep the babies with mom in the OR?

My colleagues were all on board and we set a very ambitious goal of providing skin-to-skin contact in the OR for 75% of our cesarean-born babies within 3 months of beginning the initiative. I am excited to report that after two months into our initiative we have supported immediate skin-to-skin with 53% of cesarean-born babies at our hospital. We do have a little ways to go, but it is absolutely worth celebrating that over half of babies born by cesarean are now getting to spend this valuable time with their mothers.

Prior to beginning the initiative, we did a little ground work. I spoke to the head of anesthesia about our plan. While some of his colleagues were not as enthusiastic about it as I had hoped, we got the go-ahead to move forward on a case-by-case basis. As the anesthesiologists have all been able to witness the beauty of this time, they are now all very supportive (or at least not negative) about it! We also decided to clearly define the criteria for both mom and babies to participate in the initiative (stable vital signs, no O2 requirement or respiratory distress for baby, no nausea/vomiting for mom, mom wants to participate, etc). We got the full support of the Neonatal Nurse Practitioners who attend all cesareans and let the pediatricians know that the babies would not be coming back to labor and delivery for their first admission exam as soon as they previously had been. We were all set to begin on December 1st, 2010.

Just a few days before Christmas, I was working with a first-time laboring mom and her partner. Kelly was in the middle of a medically indicated induction, and was hoping for a vaginal birth with minimal intervention. As the day progressed and despite that fact that she had been working extremely hard for many hours, she experienced very little cervical change. She was exhausted and disheartened by the news. At that point she decided to receive an epidural. After many more hours, and despite exhausting all other options, there was still no cervical change. Kelly and her physician agreed that a cesarean birth was necessary. As I was preparing her for this change in plan, I let her know that there was a good possibility that at least one part of her birth plan would not be disturbed. All went as planned. Both Kelly and and her baby Simone did very well and met our defined criteria. Not only did we place Kelly and baby Simone skin to skin in the OR for nearly 30 minutes, Simone even breastfed briefly in the OR!

When she later sent me copies of the photos I took of this special time with their camera, Kelly said:
It was incredibly meaningful to have Simone with me immediately after her birth. That very special moment of togetherness is what so many mothers look forward to, and I did, too: After 9 months of pregnancy and the effort of labor, it felt like a huge reward to finally touch our baby, to face her and have her in my arms. A cesarean birth really enforces a distance between mom and child, but the opportunity to embrace Simone right away really did help me overcome those feelings of alienation. It allowed me to be one of the first to welcome her into the world, which is, I think, a mother's right--certainly it's something I think all moms hope for.
Pictures of Kelly and Simone in the OR:

Cindy, a LD RN, loves witnessing the bonding and connectedness that skin-to-skin in the OR promotes. “It makes it so much more real,” she commented. Kristi (RN) added that “it makes the surgical birth experience so much more personal and meaningful.” As a Birthing From Within mentor as well as and LD nurse, I know in my heart that cesarean birth is still a sacred time for new families. All births, cesarean or vaginal, represent not only the birth of a baby, but also the birth of a mother, a father and a family. My hope is that supporting ways to make cesarean birth feel less clinical and more sacred will save a lot of heartache, feelings of disconnectedness, and feelings of loss over an unexpected and often unwished-for outcome. Allowing moms and babies to connect immediately after any birth is the right thing to do, and I feel it is my job to protect this sacred time.

I believe that with a little time, patience and education, all LD departments can do what we are now doing to support skin-to-skin for all mothers and babies. If you are interested in learning more about how you too can bring skin-to-skin in the OR in your hospital, please don’t hesitate to contact me. (Send Rixa an email, and she will forward it on to me.)


  1. Beautiful, perfect! Do what you can, when you can!

  2. After a friend of mine's c-section the nurse turned to her husband (I guess my friend was unable to hold the baby herself) and told him to take off his shirt and hold their baby!

  3. This is great! I'm a relatively new nurse (3 years nursery experience), and I just began attending births. My training was very specific - make sure to do all newborn procedures immediately so that you are free to attend all the other births! Our inner-city hospital has nearly 3,000 births per year. It is not unusual to have between 5 and 6 births to attend per 8 hour shift (or more!). When asking other nurses if we can let the moms have more time with the babies before taking them over to the radiant warmer for measurements, meds, assessments, etc., I was told "you might miss something if you get called to another birth." It really does get crazy down in L&D and it is really hard to get back to the "procedures" if you don't do them right away. As for skin-to-skin, while the evidence clearly shows this is beneficial, the older nurses contend that babies will get cold if not handed to the mother swaddled in at least 3 or 4 blankets. I'm very encouraged by this post though... that one nurse's behavior can change the culture of birth for an entire hospital. Love it! And I'm definitely going to use that article you referenced about STS around my unit! Thanks for being an inspiration.

  4. I forgot to mention that the DVD "Skin to skin: the first hour after birth" was also a great resource. I think it was especially helpful in getting to see this done in the OR with minimal disturbance to the surgeon and anesthesiologist. Rixa reviewed it within the last couple of months.
    It is very inexpensive, you might try getting your department educator on board and trying to purchace it.

    I understand how this can be difficult in high volume departments. I worked in a hospital that delivered 4500/yr. There are A LOT of nursing responsibilities in a facility that size and few resources. One comment I have heard from staff is that it actually seems to make their job a little easier. Babies breastfeed more easily and so far I have never had to deal with a hypothermic baby, even in the OR. If you always bring the conversation back around to "what is best for moms and babies" how can anyone argue with you. The research is very very clear that this is best. Also try visiting the lamaze website and look at Healthy Birth Practice #6: Keep Mother and Baby Together- It's Best for Mother, Baby and Breastfeeding for more info on talking with older generation nurses who are resistent to this change.
    Finally, if you have to ease into this, why not get the baby right to mom and do a few of your tasks right there; head circumfrance, vit K, erythromycin-although i try to wait on this to allow baby and mom time for eye contact, you can even do your gestational age exam on mom's chest. You can document while mom and baby are enjoying each other, and then take the baby just breifly for length and weight. Or you can do this vise versa if you are getting tons of push back from the LD nurse. Take the baby right to warmer but quickly complete only what can't be done on mom's chest, then bring him back to her chest to finish up your tasks. Best of luck! Get some allies, do your research. You can do it! Oh, one last thing. Google skin to skin in the OR. THere is a very new study out that demonstrates that babies will not get hypothermic in the OR if they are kept skin to skin with mom.

  5. Wonderful post!! So glad to hear that some L&D nurses and hospitals are taking steps to implement this wonderful practice!

    This post reminds me of one of my favorite posts, from Laura Keegan, author of "Breastfeeding with Comfort and Joy": Mothers Yearn for Their Babies at Birth.

    Thank you for working to keep moms and babies together, even after a C-section!


  6. Wonderful post!! So glad to hear that some L&D nurses and hospitals are taking steps to implement this wonderful practice!

    This post reminds me of one of my favorite posts, from Laura Keegan, author of "Breastfeeding with Comfort and Joy": Mothers Yearn for Their Babies at Birth.

    Thank you for working to keep moms and babies together, even after a C-section!


  7. What an inspiring story of positive change!!
    I was blessed to have a full hour of skin-skin with my last baby including over 30 minutes of active nursing. My OB left the room before my baby left my arms :D

  8. As a mom who had an unscheduled c-section, hooray for proactive nurses! Because I had not been planning a c-section, I didn't even think about the issue of skin-to-skin in the OR. If I'd been in your hospital, this new and super-naive mom would have had that blessing without having to fight for it myself!

  9. I wish I would have gotten to do this with ANY of my 5 babies besides my one homebirth. Really great stuff.

  10. Alethea~ great work
    Can you come work with me????
    I'm trying to get this far too!
    Good to hear it's working elsewhere!

  11. It's wonderful to hear another hospital is getting on board with this. I've mention on this blog before that my husband held our baby skin to skin after my c-section. At the time I consented to the surgery, I didn't even have the presence of mind to ask about it, but our wonderful nurse told him to take his own shirt off under the scrubs so he could tear them open and hold her. And, I was able to hold her skin to skin once I was in recovery and able to wiggle my toes.

  12. I had my first 2 babies by cesarean and you're right, that separation is one of the worst thing about cesareans. You are just biologically programmed to want, to NEED that baby on you, right with you, and then to not have access is so incredibly hard.

    I saw my first baby only for a very few seconds in recovery and then not again for EIGHT hours. That was a terrible cesarean, but I think that's the thing I regret the most, that she was mostly alone for all that time. Breaks my heart to think of it.

    In my second cesarean, my baby at least stayed in the O.R. with me, although there was no skin-to-skin. It made a huge difference just to have him there, but it would have been that much better to have had him skin-to-skin. The pictures in your post really made me yearn for what could have been. They were beautiful.

    I did get skin-to-skin with my VBAC babies so that helped, but I'll never stop being a little sad over missing that with my first two.

    How refreshing and encouraging to hear of L&D nurses working so hard to enhance bonding like this and to implement evidence-based care that makes so much sense. Thank you for your work on behalf of babies and mommas everywhere. It DOES make a difference.

  13. Great post-this is just what is needed, changes in hospital policy so parents don't have to fight. Educating parents is not enough, they need support at the hospital too-and not just doulas-but policies.

  14. I'm a first-time expectant mother and just want to say thank you for the advocating you're doing for moms and babies and what's ultimately best for them--being together. There are so many fears you experience as a first-timer, but one of my biggest ones is knowing the people who will be there at the birth have my best interests at heart, physically and emotionally. Thank you for your efforts and the example you're setting in the medical field. From my little one and me--it means a lot to us!

  15. Thank you for this wonderful article, Alethea. We hope it inspires nurses and doctors all over the world to increase mother-and-baby-centered care. We'd also like people to read what Pam England, author of "Birthing From Within," has shared about cesareans on her new blog.

  16. Pam England's two posts about humane cesarean in her "50 Ways to Change Birth in Our Culture" blog series:

  17. Your patients are very, very lucky to have you as their nurse. Heck, the hospital is lucky to have you as their nurse!

    I'd love to see an article about the use of the term "cesarean birth" vs. c-section. Even if it's a short one.

  18. Alethea and all the caring staff at your hospital, I applaud your making compassionate changes in the culture of your hospital and community. The photos were really touching.
    So glad to know you!

  19. is there anything i can do as an expectant mom to facilitate skin-to-skin contact in the OR after a planned cesarean (due in 6 weeks)? hospital policy doesn't seem skin-to-skin friendly, and OB docs don't seem to be on board. i have gestational diabetes and will start having weekly NSTs at labor and delivery on friday...would talking to the nurses about it help? i'm printing this blog post and the article it links to for my doc as well.


  20. I realize that I'm a year late in commenting on this post but I've just discovered this blog and am catching up. I figured I'd go ahead and comment in case anyone else is doing the same. I'm an ob/gyn at a mid-sized community hospital in south-central Indiana. We do ~1300 deliveries/year. Last year we started working toward receiving Baby-Friendly certification and part of that has involved changing our skin to skin policy. I agree with the author that it truly seems to improve the initial bonding experience. The babies cry less, breastfeed much more quickly, and anecdotally I've seen less postpartum hemorrhage. Looking back, I realize that I did skin to skin with both of my own deliveries long before it was ever "trendy". As a physician it doesn't bother me a bit (assuming there is no medical emergency occuring) and my patients seem to love it!

    Rachel Reed MD

    1. Hi Rachel,

      Thanks for commenting! So glad to hear your hospital is working towards BF. Where in Indiana are you?

  21. Hi Rixa - Would you be able to have Alethea write to me? I have some questions about sts for her. Thanks!

  22. Althea, I absolutely love all your skin to skin contact photos. I was wondering if I could have your permission to use one of them for a recruitment poster for my study on maternal skin to skin contact in the operating room. I am looking at RNs opinions about the facilitators and barriers to maternal SSC in the OR in order to help program implementation and development. If you could contact me via that would be greatly appreciated. Thank you for your amazing work and I look forward to hearing from you. Have a wonderful day!

    Magdalena Dobosiewicz


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